Retrograde Submental Intubation After Faciomaxillary Trauma

Abstract

To the Editor: We read with great interest the case report (1) describing the successful use of retrograde submental tracheal intubation in a patient with faciomaxillary trauma. We congratulate the authors for their successful management of their patient and agree that their novel technique is relatively safe and produces acceptable cosmetic results. We are curious, however, to know why the authors completely discounted the use of fiberoptic nasotracheal intubation (NTI). Although every student of anesthesia and virtually every textbook states that NTI is contraindicated in the presence of a basal skull fracture, the evidence for this is surprisingly sparse (2). Contrary to conventional wisdom, what published evidence there is suggests that NTI in patients with cerebrospinal fluid rhinorrhea does not adversely affect outcome (3,4). In patients with an untraumatized airway, the morbidity associated with NTI is reported to be low (5). In patients with faciomaxillary trauma, reports of successful fiberoptic NTI stress the importance of assessing the patency of the nasal passages with computed tomography (2,6,7). We would be very interested to know whether the patient described by Arya et al. had specific computed tomography findings that absolutely precluded fiberoptic NTI. If the nasal passages were not distorted or obliterated, might NTI have been feasible? P. Saravanan, MD, FRCA J. E. Arrowsmith, MD, FRCP, FRCA Department of Anaesthesia Papworth Hospital Cambridge, UK [email protected]